Skeletal survey on pediatric patient
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MRD 510 – MEDICAL IMAGING IVTITLE : SKELETAL SYSTEM SURVEY
ON PEDIATRIC PATIENT
Lecturer: Dr. Hajah Shahridah Binti KassimPresenter:
Nur Syafiqah Binti Jasmin (2012864964)Noor Farahuda Binti Mustafah Maarof (2011236456)
Presentation OverviewO Brief Description
O Common Indications
O Role of Radiographer
O Skeletal Survey’s Protocol
O Recommended Parameters
O Immobilization Techniques
O Radiation Protection
O Summary
O References
1.0 - SKELETAL SURVEY
Definition:
“A systematically performed series of radiographic
images that encompasses the entire skeleton or those
anatomic regions appropriate for the clinical indications.
“
What it is about???
Purposes:
To allow the detection of occult bony injuries in children with
suspected non-accidental injury (NAI)
- Obtain further information about a clinical injury,
- Aid in the dating of bone injury
Help in diagnosing the unknown abnormalities from the normal
developmental changes and other anatomic variants
Help in detection of any underlying skeletal disorder that may mimic
the fractures
(The American College of Radiography, 2014)
2.0 COMMON INDICATIONS
Known or suspected child abuse, in which the children’s physical, emotional or sexual assaulted a.k.a Non-accidental Injury (NAI)
Skeletal dysplasia (OsteogenesisImperfecta), syndromes (Bony Dysmorphic Disorder) and metabolic disorder (Paget’s disease)
Neoplasia and related disorder, such as Multiple Myeloma and Metastatic Bone disease.
(Dr. Prashant Mudgal et al, 2014)
3.0 ROLES OF RADIOGRAPHERBefore examination:
The request form of the skeletal survey examination should
be reviewed
- the examination must be requested by a physician or other
appropriately licensed health care provider
- it must be provided with sufficient medical information, which are: 1)
signs and symptoms, and/or 2) relevant history, and 3) specific
reason for undergoing the examination
At least two radiographers are available for the examination
- one is available for handling the patient, while the other one is
available for preparing the machine and equipment, including for
selecting the exposure factor and processing the images.
Another professional who is responsible for the child’s safety
on radiology department should be available.
(Royal College of Paediatrics and Child Health, 2008)
Cont.. All the equipment and the room must be prepared before call
the patient, including pre-selecting exposure factor. Make
sure the immobilization devices are available and the room
is tidy.
Clearly identify the patient identification.
Give a brief explanation to the patient and guidance,
including a careful and accurate presentation clinical
concerns, a description of imaging procedures that are being
planned, explanation of the reasons for procedure and the
risk and benefit of procedure.
Informed consent must be obtained by referring pediatrician.
Make sure all the metal or any object-inducing artefact are
removed.
(Royal College of Paediatrics and Child Health, 2008)
Cont..During examination:
The guidance is allowed to be within the examination
room if;
- Patient is uncooperative
- The guidance is not pregnant (if women)
All the radiographs should have the correct patient
name, side marker, date and time of examination.
The radiographers’ name who are performing the
procedure should be recorded
Further radiographic projections may be required,
according to the supervising radiologist’s instruction.
(Royal College of Paediatrics and Child Health, 2008)
Cont.. After examination:
The patient should be returned for ongoing care
to referring clinician after the examination is
completed.
An official interpretation (the final report) of
examination made by radiologist should be
included in the patient’s medical record.
A concise description of all area of definite and
suspected abnormalities should be provided on
the report.
(Royal College of Paediatrics and Child Health, 2008)
4.0 - PROTOCOLS
SKULL
Anterior posterior (AP), lateral, and Townes view
(if clinically indicated)
CHEST
AP including the clavicles
Oblique views of both of the sides of the chest to
show ribs (left and right oblique)
ABDOMEN
AP of abdomen including the pelvis and hips
PROJECTIONS RADIOGRAPH
S
(Royal College of Paediatrics and Child Health, 2008)
cont..
SPINE
Lateral: may require separate exposures of the
cervical, thoracic and thoracolumbar regions /
separate radiograph
LIMBS
PA of both hands
AP of both radius-ulna
AP of both humerus
AP of both feet
AP of both tibia-fibula
AP of both femur
# If clinical signs suggest a focal injury, such as
soft tissue swelling or tenderness, two
projections at 90°should be performed.
PROJECTIONS RADIOGRAPH
S
(Royal College of Paediatrics and Child Health, 2008)
Brain bounce back and forth:
• Intracranial injuries
Compressive Force
at Thorax:
• Rib Fractures
Leg Flailing Back-Forth:
• Corner Fracture of Metaphyseal
• Bucket Handle Fractures
Shaken Baby Syndrome
(Robben, 2006)
RIB FRACTURES
(Robben, 2006)
Yellow arrow: callus develops
CORNER FRACTURES
(Robben, 2006)
BUCKET HANDLE FRACTURES
(Robben, 2006)
SKULL FRACTURES
(Robben, 2006)
DIAPHYSEAL FRACTURES
(Robben, 2006)
FRACTURE HEALING
(Robben, 2006)
Follow-Up Procedure
Skeletal survey is recommended to be
repeated in approximately 2 weeks from the
initial skeletal survey in cases of suspected
physical abuse in children less than 1 year of
age.
Follow up or repeat skeletal survey has shown
positive result in finding additional information
in 46-61% of cases.
Additional information detected are usually rib
fractures and metaphyseal lesions
(Giardino, Lyn, & Giardino, 2014)
Follow-Up Procedure
(Offiah, Rijn, Perez-Roseelo, & Kleiman, 2009)
a Initial chest radiograph shows an acute left 7th rib fracture (arrow).
b Initial oblique images of the chest better demonstrate the left 7th rib
fracture and a possible left 8th rib fracture (arrows).
c Follow-up oblique images of the chest obtained 2 weeks later show
healing left 7th, 8th and 9th rib fractures
5.0 RECOMMENDED PARAMETERS
As low as reasonably achievable (ALARA)
Optimal high-detail digital imaging system
Sufficient spatial resolution and signal-to-noiseratio characteristics to detect subtle skeletalinjuries
Minimum source image distance is 100 cm (40”)
Precise positioning and collimation over eachanatomic region are essential
Chest imaging should use bone detail techniquefor suspected abuse cases
(The American College of Radiography, 2014)
6.0 IMMOBILIZATION DEVICES
(Freeman, 2012)
7.0 RADIATION PROTECTIONCorrect Patient
Correct procedures
Ensure that the image taken has not yet been taken in the emergency department, to avoid repetitive procedure that can increase dose received by the child
Appropriate collimation
Patient’s shielding in area not in the region of interest
As low as reasonably achievable (ALARA)
Skeletal survey should not consist of a single image of the patient’s skeleton (known as baby-gram) because the detail is not sufficient to recognize subtle injuries.
Grids are not routinely used to image spine, pelvis, skull
and abdomen on children under 6 months
(The American College of Radiography, 2014)
8.0 SUMMARY
O There is restrictive definition of positive Skeletal Survey
results for example finding of a fracture that was completely
unsuspected
O 11% to 50% of cases with Skeletal Survey results were
positive.
O In 50% of these cases. the Skeletal Survey results
influenced directly the decision to make a diagnosis of
abuse cases.
O Children 6 months of age has the highest rate of positive
Skeletal Survey results and it is recommended that a
Skeletal Survey should be completed for them with
suspected abuse cases.
(Duffy, Squires, Fromkin & Berger, 2011),
9.0 REFERENCESDuffy, S.O., Squires, J., Fromkin, J.B., & Berger, R.P. (2010). Use of skeletal surveys to evaluate
for physical abuse: Analysis of 703 consecutive skeletal surveys. Retrieved
September 28, 2014, from http://pediatrics.aappublications.org/content/
127/1/e47.full.html
Freeman, C. (2012). Imaging children; immobilisation, distraction techniques and use of sedation.
Society of Radiographers. Retrieved September 27, 2014, from http://www.sor.org
Giardino,A.P., Lyn.M.A, & Giardino,E.R. (2010). A practical guide to the evaluation of child
physical abuse and neglect. Springer Science & Business Media: London.
Offiah, A., Rijn, R.R.V., Perez-Rosello, J.M., & Kleinman, P.K. (2009). Skeletal imaging of child abuse
(non- accidental injury).
Radiopedia. (2014). Skeletal Survey. Retrieved September 25, 2014, from
http://radiopaedia.org/articles/skeletal-survey
Robben, S. (2006). Diagnostic imaging in child abuse non accidental trauma. Retrieved September
28, 2014, from http://www.radiologyassistant.nl/en/p43c63c41ef792/diagnostic-
imaging-in-child-abuse.html
Royal College of Paediatrics and Child Health. (2008). Standards for radiological investigations of
suspected non-accidental injury. Retrieved September 23, 2014, from
https://www.rcr.ac.uk/docs/radiology/pdf/RCPCH_RCR_final.pdf
The American College of Radiography. (2014). ACR-SPR practice parameter for skeletal surveys in
children. Retrieved September 24, 2014 from
http://www.acr.org/QualitySafety/Standards-Guidelines/Practice-Guidelines-by-Modal
ity/Pediatric
The Royal College of Radiologists. (2011). Imaging for non-accidental injury (NAI): use of
anatomical markers. Retrieved September 28, 2014, from
https://www.rcr.ac.uk/docs/radiology/pdf/BFCR(11)5_RCR_COR_NAI.pdf
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